MEDICARE: SUSAN SHOTTS RT (R)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	CRT18236	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CRT18236	OTHER	AZ	STATE F AZ LICENSE

General Provider Information

NPI Number	:	1295345783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN SHOTTS RT (R)

Provider Business Mailing Address
First Line	:	555 S 107TH ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-5703
Country	:	US
Telephone Number	:	484-272-4239
Fax Number	:

Provider Business Practice Location Address
First Line	:	861 N HIGLEY RD STE B101
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85234-9602
Country	:	US
Telephone Number	:	480-813-9600
Fax Number	:	480-813-9601

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2020
Last Update Date	:	08/09/2020

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